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Decreased mucosal expression of intestinal alkaline phosphatase in children with coeliac disease


A major function of the enzyme intestinal alkaline phosphatase (iAP) is the detoxification of lipopolysaccharide (LPS), the ligand of Toll-like receptor 4 (TLR4). Hence, iAP has a role in the defence of maintaining intestinal barrier integrity. As intestinal barrier integrity is impaired in coeliac disease (CD), we tested the expression and localization of iAP in duodenal mucosa specimens from children with newly diagnosed CD (n = 10), with CD on gluten-free diet (GFD) (n = 5) and compared to those from ten healthy children. The mRNA and protein expression was determined by RT-PCR and Western blot analysis, respectively. Tissue localization of iAP and TLR4 was determined by immunofluorescence staining. iAP protein expression level was significantly lower than normal in newly diagnosed CD, while it was normalised in children on GFD. iAP and TLR4 colocalized at the epithelial surface of duodenal mucosa in each group of subjects enrolled. The finding of decreased iAP protein levels in newly diagnosed CD is consistent with its role in decreased intestinal barrier integrity. The latter may be the result of decreased LPS-detoxifying ability.


Coeliac disease (CD) is a chronic enteropathy that is triggered by chronic exposure to gluten protein of wheat, barley and rye. Both the innate and the adaptive parts of the immune system are involved in its pathogenesis in genetically predisposed individuals [1, 2]. The diagnosis of CD is based on serologic tests, mucosal biopsy and the effects of gluten-free diet (GFD) on the symptoms [3]. The innate immune system in the pathogenesis of CD includes Toll-like receptors (TLR), a family of bacterial and viral pattern recognition receptors [4]. Under physiological circumstances TLRs play a crucial role in preserving a regulated homeostasis within the gut by the elimination of pathogens and toleration against commensal microbes [5]. TLR4, a member of the transmembrane receptor TLR family, is activated by lipopolysaccharide (LPS) present in the outer membrane of Gram-negative bacteria [6]. The uncontrolled activation of TLR4 may induce mucosal loss and induction of a proinflammatory cascade [7]. Recently, our group has shown increased mRNA and protein levels of TLR4 in the duodenal mucosa of children with newly diagnosed CD, and these levels further increased in CD patients on GFD [8]. In addition, we found a higher prevalence of TLR4-positive dendritic cells and monocytes in the peripheral blood of patients newly diagnosed with CD compared to controls [9].

The enzyme intestinal alkaline phosphatase (iAP) is expressed in large quantity on the apical surface of the enterocytes [10]. iAP may play a pivotal role in the maintenance of intestinal barrier integrity by detoxification of LPS, the ligand of TLR4 [11, 12]. iAP is able to dephosphorylate the disphosphoryl lipid A part of LPS. This avoids pathological activation of TLR4 and the MyD88-dependent signalling events [13]. The precise role of iAP in CD is not defined, but according to previous studies in an animal model of inflammatory bowel disease, exogenously administered iAP improved the histological signs of inflammation [14]. A recent clinical study also reinforced the beneficial effects of exogenous iAP products in inflammatory bowel disease patients [15]. For CD, the data available for iAP suggest that iAP enzyme activity decreases in the duodenal biopsy specimens and strongly correlates with histological signs [16], but the iAP protein levels were not investigated.

The aim of our study was to collect additional data on iAP protein and mRNA expression in CD. We also tested whether or not iAP and TLR4 are colocalized in duodenal mucosa.

Materials and methods

Patients and duodenal biopsies

We enrolled ten children (two boys, eight girls; median age, 4 years; range, 2–12 years) with newly diagnosed CD and five children (two boys, three girls; median age, 12 years; range, 6–13 years) with GFD-treated CD and ten controls (five boys, five girls; median age, 9.5 years; range, 2–16 years) in the study. CD was diagnosed by the criteria of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition [17, 18]. Screening for CD was performed using IgA anti-tissue transglutaminase [19]. High level of anti-tissue transglutaminase and villous atrophy was demonstrated in all patients with newly diagnosed CD. Children on GFD had full clinical and histological remission supported by normal blood levels of anti-tissue transglutaminases. The time frame between the first and the second biopsies of patients on GFD (GFD-treated CD) was 1.5 years (range, 0.5–2.5 years). The control group included children with chronic abdominal pain or chronic diarrhoea referred to the outpatient clinic. Normal blood levels of anti-tissue transglutaminases were demonstrated, and no histological alterations were present in their duodenal biopsy specimens. The subjects' anthropometric parameters in each group were comparable (Table 1). Written informed consent was obtained from parents prior to the procedure. The study was approved by the Semmelweis University Regional and Institutional Committee and Research Ethics.

Table 1 Clinical characteristics of newly diagnosed patients with CD and patients treated on GFD

RNA isolation and real-time PCR

Total RNA was isolated from the duodenal biopsy samples. Total RNA was reverse-transcribed to generate first-strand cDNA. iAP mRNA expression was determined by real-time PCR on a Light Cycler480 (Roche Diagnostics, Mannheim, Germany). PCRs were performed containing RealTime ready Catalog Assay primer (Roche Diagnostics), Brilliant II QPCR Master Mix (Stratagene, Cedar Creek, TX, USA) and cDNA. Conditions for iAP include one cycle, 95°C, 10 min (denaturation), followed by several cycles at 95°C, 20 s and 60°C, 1 min (annealing and extension). The internal control was glyceraldehyde-3-phosphate dehydrogenase (GAPDH). The mRNA expression of GAPDH was determined using Brilliant II Fast SYBR Green QPCR Master Mix (Stratagene), PCR primers (forward: 5-CAC CAC CAT GGA GAA GGC TG-3′; reverse: 5-GTG ATG GCA TGG ACT GTG-3′, Invitrogen, CA, USA) and cDNA. Conditions for GAPDH include one cycle, 95°C, 2 min followed by 50 cycles at 95°C, 20 s, and 60°C, 40 s. Results were analysed by Light-Cycler software 480 (Roche Diagnostics).

Protein isolation and Western blotting

Duodenal biopsy samples were homogenized in lysing solution, and the total protein concentrations were analysed by DC Protein Assay (Bio-Rad Laboratories, Hercules, CA, USA). An equal amount of protein samples, 0.5 μg from each sample, was separated by 10% sodium dodecyl sulphate–polyacrylamide gel electrophoresis (120 V, 40 mA, 120 min) (Penguin™ Dual-Gel Water Cooler Systems, Owl, NH, USA) and transferred to nitrocellulose membrane (GE Healthcare, Little Chalfont, UK) (70 V, 220 mA, 120 min) (MiniTank™ electroblotter, Owl). Membranes were blocked in 1% fat-free dry milk solution (1 h) and incubated with iAP-specific rabbit polyclonal antibody (1:1,000, 1 h) (AbCam, Cambridge, UK). Equal protein loading was confirmed by ß-actin-specific (C-11) goat polyclonal IgG antibody (1:100) (Santa Cruz Biotechnology Inc., Santa Cruz, CA, USA). The membrane was incubated with peroxidase-conjugated secondary anti-rabbit IgG or donkey anti-goat IgG antibodies (1:2,000, 30 min) (Santa Cruz Biotechnology Inc.). Immunoreactive bands were visualized using the enhanced chemiluminescence Western blotting detection reagents (GE Healthcare). Bands were analysed with software Image J. 1.42q (National Institutes of Health, USA). The values were expressed as relative optical density.

Immunofluorescence staining

The snap-frozen duodenal biopsy samples were imbedded in Shandon cryomatrix (ThermoElectron Co., Waltham, MA, USA) and cut to 3–4-μm slides. For iAP and TLR4 double immunofluorescence, iAP-specific rabbit polyclonal antibody and TLR4-specific goat polyclonal antibody were applied (1:100, 1 h) (Abcam Plc). Alexa Fluor 488 donkey anti-goat and Alexa Fluor 568 goat anti-rabbit antibodies were used as secondary antibodies (Invitrogen). Zeiss LSM 510 Meta confocal laser scanning microscope (Carl Zeiss, Jena, Germany) was used with ×20 Plan Apochromat (NA = 0.8) and ×63 Plan Apochromat oil immersion differential interference contrast objectives (NA = 1.4).

Statistical analysis

Data were analysed using Statistica 7.0 software (StatSoft Inc., Tulsa, OK, USA). After testing the normality with Shapiro–Wilk's test, nonparametric Mann–Whitney U test was used. Values of p ≤ 0.05 were considered to be significant and expressed as mean±SD.


iAP mRNA expression

Real-time PCR was performed to determine the mRNA expression of iAP in children with newly diagnosed CD, children with GFD, and healthy controls. As shown in Fig. 1, iAP mRNA expression was decreased in the duodenal mucosa of children with newly diagnosed CD compared to healthy controls; however, the difference failed to reach significance. There was no significant difference in children maintained on GFD and newly diagnosed CD groups, but the iAP mRNA expression of the GFD group has started to normalise.

Fig. 1

iAP mRNA expression in the duodenal mucosa of children with coeliac disease (CD), children on GFD and healthy controls. mRNA expression of iAP was determined by computerized analysis of RT-PCR. Optical density of the investigated RT-PCR products was corrected for that of GAPDH. Data are expressed as mean±SD. The mRNA expression of iAP in duodenal mucosa of newly diagnosed patients with CD was not significantly decreased in comparison to patients with GFD and healthy controls

iAP protein levels

We performed Western blot analysis in the duodenal biopsy specimens from newly diagnosed CD patients, children with GFD, and healthy controls, which revealed one distinct band at 60 kDa. The amount of iAP protein in newly diagnosed children with CD was significantly decreased when compared to controls (33%, p < 0.05) (Fig. 2). iAP protein levels of patients on GFD were higher than those of CD patients but lower than those of controls (Fig. 2).

Fig. 2

Protein levels of iAP in the duodenal mucosa of children with newly diagnosed CD, children on GFD, and healthy controls. Western blot analysis reveals one distinct band at a molecular weight of 60 kDa with rabbit polyclonal antibody specific to human iAP in the duodenal biopsy specimens of children with CD and with GFD, and healthy controls (a). Data for protein levels of iAP were obtained by computerized analysis of the Western blots (b). Data are expressed as mean±SD. Analysis of significance was performed by Mann–Whitney U test. *p < 0.05 vs. control

Localization of iAP and TLR4 in the duodenum

Immunofluorescence staining was performed to investigate the possible colocalization of iAP and TLR4 in patients with CD, children with GFD, and healthy controls (Fig. 3). iAP and TLR molecules clearly colocalized in a dot-like pattern in all groups studied. iAP was restricted to the epithelial surface of the duodenal mucosa, but no immunofluorescent signal was detected in goblet cells, in immune cells of the lamina propria or in the Lieberkühn cells.

Fig. 3

Localization of iAP and TLR4 in duodenal mucosa of healthy controls, children with newly diagnosed CD and children on GFD. Immunofluorescent staining using anti-iAP and anti-TLR4 antibodies staining were performed. Representative example sections of duodenum are shown: healthy controls (a), children with CD (b) and patients treated with GFD (c). Differential interference contrast was used for the observation of non-labelled tissues. Double-positive cells for iAP and TLR4 are seen as yellow clusters. iAP (red) and TLR4 (green) were equally intense only at the epithelial surface in all groups studied. Nuclei are stained with blue. Bar = 20 μm


To the best of our knowledge, we are the first to demonstrate the alteration of protein expression of iAP and the localization of iAP and TLR4 in the duodenal mucosa of children with newly diagnosed CD, children maintained on GFD, and healthy controls. We found significantly reduced iAP protein levels in the duodenal mucosa of newly diagnosed CD patients, compared to healthy controls. The iAP protein levels of children maintained on GFD were lower than those of controls, but higher than those of patients with CD.

iAP is a recently identified enzyme with a major role in intestinal barrier integrity. Its possible contribution to CD is highlighted by Prasad et al. who reported that the activity of iAP and other brush-border enzymes correlates with histologically moderate and severe lesions in CD duodenal specimens [16] and that these abnormalities vanish on GFD [20, 21]. In line with these results, we found decreased iAP protein levels in newly diagnosed patients with CD that tended to normalise on GFD. We have also shown in a previous study that the increased expression of tight-junction molecules such as claudin 2 and 3 might contribute to the change of barrier function of the duodenal mucosa [22] and to increased permeability and consequential malabsorption. The decreased level of iAP may be a further element contributing to the degradation of intestinal barrier integrity [11]. Nevertheless, the decreased iAP level in untreated patients with CD is probably an inflammation-related, nonspecific finding for CD; however, our results (colocalization with TLR, TLR–LPS-detoxifying ability) may add new pieces to the puzzle of the pathomechanism of CD.

The possible contribution of iAP to intestinal barrier integrity is thought to be mediated by its action on TLR ligands. Indeed, we observed that iAP and TLR4 occur in a colocalized manner. Previously, we have shown increased TLR4 expression in newly diagnosed patients with CD [8]. Theoretically, the lower-than-normal iAP together with a higher-than-normal TLR4 expression results in an imbalance in iAP/TLR4 ratio and, hence, an increased inflammatory response to LPS present in the gut. These data support that innate immunity and, particularly, TLRs are major players in disturbed intestinal barrier integrity in CD.

In summary, we found decreased iAP duodenal mucosal protein expression in children with newly diagnosed CD. In addition, a strong colocalization of iAP and TLR4 at the epithelial surface of duodenal mucosa was found. These findings suggest that iAP plays an important role in the restitution of mucosal barrier integrity and in innate immunity.


  1. 1.

    Maynard CL, Weaver CT (2011) Immunology: context is key in the gut. Nature 471:169–170

  2. 2.

    Dickson BC, Streutker CJ, Chetty R (2006) Coeliac disease: an update for pathologists. J Clin Pathol 59:1008–1016

  3. 3.

    Ensari A (2010) Gluten-sensitive enteropathy (celiac disease): controversies in diagnosis and classification. Arch Pathol Lab Med 134:826–836

  4. 4.

    Cario E (2008) Barrier-protective function of intestinal epithelial Toll-like receptor 2. Mucosal Immunol 1(Suppl 1):S62–S66

  5. 5.

    Abreu M, Fukata M, Arditi M (2005) TLR signaling in the gut in health and disease. J Immunol 174:4453–4460

  6. 6.

    Triantafilou M, Triantafilou K (2002) Lipopolysaccharide recognition: CD14, TLRs and the LPS-activation cluster. Trends Immunol 23:301–304

  7. 7.

    Baumgart D, Thomas S, Przesdzing I, Metzke D, Bielecki C, Lehmann S, Lehnardt S, Dörffel Y, Sturm A, Scheffold A, Schmitz J, Radbruch A (2009) Exaggerated inflammatory response of primary human myeloid dendritic cells to lipopolysaccharide in patients with inflammatory bowel disease. Clin Exp Immunol 157:423–436

  8. 8.

    Szebeni B, Veres G, Dezsofi A, Rusai K, Vannay A, Bokodi G, Vásárhelyi B, Korponay-Szabó I, Tulassay T, Arató A (2007) Increased mucosal expression of Toll-like receptor (TLR)2 and TLR4 in coeliac disease. J Pediatr Gastroenterol Nutr 45:187–193

  9. 9.

    Cseh Á, Vásárhelyi B, Szalay B, Molnár K, Nagy-Szakál D, Treszl A, Vannay Á, Arató A, Tulassay T, Veres G (2011) Immune phenotype of children with newly diagnosed and gluten-free diet-treated celiac disease. Dig Dis Sci 56:792–798

  10. 10.

    Lallès JP (2010) Intestinal alkaline phosphatase: multiple biological roles in maintenance of intestinal homeostasis and modulation by diet. Nutr Rev 68:323–332

  11. 11.

    Bates J, Akerlund J, Mittge E, Guillemin K (2007) Intestinal alkaline phosphatase detoxifies lipopolysaccharide and prevents inflammation in zebrafish in response to the gut microbiota. Cell Host Microbe 2:371–382

  12. 12.

    Goldberg RF, Austen WG, Zhang X, Munene G, Mostafa G, Biswas S, McCormack M, Eberlin KR, Nguyen JT, Tatlidede HS, Warren HS, Narisawa S, Millán JL, Hodin RA (2008) Intestinal alkaline phosphatase is a gut mucosal defense factor maintained by enteral nutrition. Proc Natl Acad Sci U S A 105:3551–3556

  13. 13.

    Geddes K, Philpott D (2008) A new role for intestinal alkaline phosphatase in gut barrier maintenance. Gastroenterology 135:8–12

  14. 14.

    Tuin A, Poelstra K, de Jager-Krikken A, Bok L, Raaben W, Velders M, Dijkstra G (2009) Role of alkaline phosphatase in colitis in man and rats. Gut 58:379–387

  15. 15.

    Lukas M, Drastich P, Konecny M, Gionchetti P, Urban O, Cantoni F, Bortlik M, Duricova D, Bulitta M (2010) Exogenous alkaline phosphatase for the treatment of patients with moderate to severe ulcerative colitis. Inflamm Bowel Dis 16:1180–1186

  16. 16.

    Prasad K, Thapa B, Nain C, Sharma A, Singh K (2008) Brush border enzyme activities in relation to histological lesion in pediatric celiac disease. J Gastroenterol Hepatol 23:e348–e352

  17. 17.

    Ribes-Koninckx C, Mearin M, Korponay-Szabó I, Shamir R, Husby S, Ventura A, Branski D, Catassi C, Koletzko S, Mäki M, Troncone R, Zimmer K, The ESPGHAN Working Group on Coeliac Disease Diagnosis (2012) Coeliac disease diagnosis: espghan 1990 Criteria or need for a change? Results of a questionnaire. J Pediatr Gastroenterol Nutr 54(1):15–19

  18. 18.

    Meijer JW, Wahab PJ, Mulder CJ (2003) Small intestinal biopsies in celiac disease: duodenal or jejunal? Virchows Arch 442:124–128

  19. 19.

    Dalgic B, Sari S, Basturk B, Ensari A, Egritas O, Bukulmez A, Baris Z, TurkishCeliac Study Group (2011) Prevalence of celiac disease in healthy Turkish school children. Am J Gastroenterol 106:1512–1517

  20. 20.

    Gorgun J, Portyanko A, Marakhouski Y, Cherstvoy E (2009) Tissue transglutaminase expression in celiac mucosa: an immunohistochemical study. Virchows Arch 455:363–373

  21. 21.

    Wahab PJ, Meijer JW, Mulder CJ (2002) Histologic follow-up of people with celiac disease on a gluten-free diet: slow and incomplete recovery. Am J Clin Pathol 118:459–463

  22. 22.

    Szakál DN, Gyorffy H, Arató A, Cseh A, Molnár K, Papp M, Dezsofi A, Veres G (2010) Mucosal expression of claudins 2, 3 and 4 in proximal and distal part of duodenum in children with coeliac disease. Virchows Arch 456:245–250

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We thank Mária Bernáth for her excellent technical assistance. This work was supported by grants OTKA-76316, OTKA-K81117, TÁMOP 4.2.2. B-10/1-2010-2013, and ETT-028-02. Gábor Veres and Ádam Vannay are holders of the János Bolyai Research grant; this article was supported by the János Bolyai Research Scholarship of the Hungarian Academy of Sciences.

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We declare that we have no conflict of interest.

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Correspondence to Gabor Veres.

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Molnár, K., Vannay, Á., Sziksz, E. et al. Decreased mucosal expression of intestinal alkaline phosphatase in children with coeliac disease. Virchows Arch 460, 157–161 (2012). https://doi.org/10.1007/s00428-011-1188-5

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  • Intestinal alkaline phosphatase
  • Toll-like receptor
  • Duodenal biopsy
  • Children
  • Coeliac disease